Welcome to my blog. HIV prevalence is not a reliable indicator of sexual behavior because the virus is also transmitted through unsafe healthcare, unsafe cosmetic practices and various traditional practices. This is why many HIV interventions, most of which concentrate entirely on sexual behavior, have been so unsuccessful.

Tuesday, June 29, 2010

The US has launched a new grant to help developing countries to strengthen their health systems. The term 'health system strengthening' has become quite fashionable recently. But it's usually used by defenders of the likes of PEPFAR (President's Emergency Fund for Aids Relief) and the World Bank's Global fund, who argue that their funds do not target HIV at the expense of other diseases or of health systems strengthening. Remarkably, the article about this new fund, the Global Health Initiative, flatly contradicts these claims and even reads like an admission that mistakes have been made. Such admissions are rare, but vital if serious diseases such as HIV are to be controlled.

The article ends with the conclusion that HIV was not adequately addressed because the focus was on the health sector, whereas this disease in particular is not simply a health problem. But you could argue that diarrhoeal diseases and intestinal parasites are a matter of water and sanitation, respiratory diseases are a matter of environment and housing and malaria is a combination of all of these factors and perhaps some others. None of them are 'simply' health problems.

Yet, it is true to say that you can't just reduce HIV transmission by sending everyone to a clinic and giving them counselling and drugs if they are infected and lecturing everyone who is not infected about safe sex and perhaps giving them condoms. This has been tried and has failed. Amazing amounts of money have been thrown at HIV and the result has been a continuation of very high levels of transmission and a distinct lack of understanding of why some countries and parts of countries have such profound HIV epidemics and why some do not.

So, like other diseases, HIV epidemics are not just a matter of dealing with a particular pathogen, you must also consider the host and the environment. Looking at it (and other diseases) from this point of view, there are a lot of ways of spending 381 billion Tanzanian shillings aside from on health aspects alone. Many people are said to be more susceptible to HIV infection because they don't have a choice about when, how often or with whom they have sex. Others are susceptible because they have various health conditions that make them so, for example, malnutrition, intestinal parasites, sexually transmitted infections, TB, malaria, etc.

As well as dealing with host factors, then, money could be spent on environmental factors, water and sanitation, infrastructure, gender relations, equality, poverty and many other things. But anyhow, the claim is that the money was spent on the health sector, not on health systems (supply chain management, health worker retention, information management, etc). And it seems fairly clear that money has not been spent on health systems, pace the argument for the Global Health Initiative and contra the unconvincing arguments of Global Fund and PEPFAR proponents.

But here's a thing, you could argue that those tenets of epidemiology leave out something very important, perhaps most important when the epidemic is HIV: nosocomial infections. This is where the disease is spread by medical procedures. The pathogen is clearly being introduced into a host, but artificially so and the environment is a rarefied but highly risky one. Do nosocomial infections, to some extent, elude epidemiologists altogether (or just those who work for UNAIDS, WHO or CDC and a few other institutions that have a lot of influence in the HIV industry)?

Following the pronouncements of those august institutions, you would think that nosocomial infections hardly infect anyone in developing countries, with the rare exception of some of their own employees who happen to be working in those countries and have to use the same medical facilities as the natives. Don't worry, that has probably never happened, though that doesn't stop them from warning their employees.

Ignoring other diseases, health in general, water and sanitation, nutrition, environmental conditions and structural conditions in the fight against HIV has been unbelievably stupid. Equally stupid is the failure to ensure that there were adequate health structures in place to implement various HIV prevention and treatment initiatives, however misguided some of these may have been. In fact, in countries like Kenya, health structures were being dismantled from the 1980s onwards at the instigation of institutions like the World Bank (yes, the one that came up with the Global Fund!).

In admitting that health systems have been ignored, the HIV aristocracy may be getting just a little closer to admitting that their view of HIV transmission in developing countries is in bad need of reconsideration. They still tell us that HIV is almost entirely transmitted through heterosexual intercourse in developing countries. But it would seem very hard to maintain this view when the Global Health Initiative is admitting that health systems have been ignored and this has done a lot of damage and has wasted much of the money that has been poured into HIV so far.

Huge amounts of money have been and still are being spent on trying to get people into medical facilities, to be tested and/or treated for HIV and many other diseases. Pregnant mothers are encouraged to go to clinics and to bring their babies and infants to be vaccinated. Men are being encouraged to go to clinics to be tested and/or treated for HIV and sexually transmitted diseases and even non-communicable diseases. But if health advocates want people to go to health facilities, they would need to make sure those health facilities are safe enough that people do not become infected with something as life-threatening as HIV. People need to be made aware of the risks they face in health facilities and those health facilities had better be improved quickly and thoroughly. I don’t think the admission that grotesque mistakes have been made was intended but it has certainly let the genie out of the bottle, well, one of them.

But Chalker herself simply makes the same confusion. She says that 'an anti-counterfeit law is essential in Uganda and east Africa as a whole; one only has to look at the number of deaths arising from counterfeit pharmaceutical products, electronic goods and auto spare parts'. If a drug or produce is causing death or injury, that is a health and safety problem. Branded goods can cause death and injury. Putting a brand name on a product illegally doesn't make it harmful, nor does doing so legally make it safe. The harm comes when the goods are substandard or when drugs are fake, not real drugs at all.

The distinction seems basic enough, but Chalker and the people who put together the original Kenyan bill appear unable to comprehend it. Worse still, Uganda and several other countries seem keen to follow Kenya's lead, despite the Kenyan's change of mind. Chalker and others who follow this tendency to conflate counterfeits, generics and fakes then go on to deny that their stance could jeopardize availability of affordable generic drugs, such as ARVs. But their denial sounds hollow when they go to so much trouble to confuse generics with counterfeits and fakes.

Of course, there may also be counterfeit drugs and fake drugs in circulation. When drugs are priced so that no one in developing countries can afford them, in the hope that aid money will be used to purchase them, it's not surprising that some people will try to cash in on the market for cheap drugs. If the pharmaceutical industry is concerned about the fact that it is quite easy to make a good profit from counterfeit and fake drugs, they need to sort out their own pricing policies, perhaps by taking a look at what the 'market' can tolerate. Otherwise they might be accused of depending on subsidies and of rigging the market, which would be quite intolerable.

Chalker expresses her concern at the 'extra burden counterfeiting places on health services in developing countries'. If she is worried about health services being burdened, it is branded goods she should target. If she thinks that health services will be unable to afford the growing need for ARVs, she needs to champion the cause of those producing affordable generic versions of the grossly overpriced branded drugs that her friends in the pharmaceutical industry produce.

Chalker says that IP laws should be 'well-drafted', which, presumably, all laws should. But well-drafted for whom? Intellectual property is for the benefit of industries like big pharma, not for the benefit of poor people who are sick and dying. IP laws are not, as Chalker seems to think, to protect people from harm, and I don't think anyone who knows about IP would claim something so stupid. That's why human rights activists had to fight for international law to protect people from IP laws and allow poor countries access to affordable generics. I don't believe Chalker is stupid, though. She just thinks that everyone else is.

It was established quite early on that HIV could be transmitted through blood and other bodily fluids, not just through sexual contact. This meant that people could be infected through medical procedures such as injections and blood transfusions, intravenous drug users could be infected, HIV positive mothers could pass on the infection to their babies, either in the womb, during delivery or through breastfeeding and people might even be infected by their hairdresser or manicurist, if they didn't take proper precautions. Early on in the epidemic, these considerations probably influenced the measures that countries such as Uganda took to reduce the spread of HIV. But later, as HIV became more dominated by political and religious leaders, it was treated as if it was almost entirely sexually transmitted. According to the official view, this is only true of developing countries, though.

For me, the thing that doesn’t ring true in the many allusions to Uganda’s great success in fighting HIV is that they all assume the truth of the behavioural paradigm. They all assume that because HIV is mainly sexually transmitted, what a country needs to do is tell people everything about ‘safe sex’, give them some condoms and everything will be ok. When Uganda first started putting in place measures to reduce the spread of HIV, they probably didn’t subscribe to what became the enduring fiction that drives HIV policy, national and international. But later, when donors, politicians, religious prognosticators and commercial interests become involved, Uganda said whatever was required to get the money flowing and to keep it flowing.

Because the most prominent people in the industry so much want everyone to believe that HIV is primarily sexually transmitted, they even want to believe it themselves, they have rewritten everything that happened before the fiction was created. They so much want this fiction to be true that they refuse to countenance the possibility that a certain amount of HIV, perhaps a very large amount, comes from non-sexual processes. Even though there are measures that can be taken to prevent non-sexual HIV transmission, these measures are generally not taken in developing countries. Even though we know that it is not possible to significantly influence people’s sexual behaviour just by telling them what they should and shouldn’t do, that’s what most HIV prevention programmes consist of.

Given that those who control the HIV industry and its considerable wealth base all their decisions on a fiction, it’s not surprising that others, who don’t have access to the same levels of data, expertise and other resources, weave their own fictions. A man calling himself ‘Dr’ Ayiko, seems to accept the fiction based on the behavioural paradigm. He therefore also accepts the story about Uganda reducing HIV prevalence by exhorting people to abstain from sex, be faithful to one partner and use condoms. But he feels that this approach no longer works and that one of the main reasons for the continued spread of HIV is ‘intentional’ transmission.

I assume he means the intentional spread of HIV through sexual means. He refers to the bill currently being discussed in the Ugandan parliament that would make it a capital offence to intentionally spread HIV and I think the bill is aimed at sexual transmission, though I’m not sure and I doubt if many Ugandans, including the ‘Dr’ in question, are sure either. Anyhow, Dr Ayiko says that ‘in virtually all the 112 districts [of Uganda], there are people who boast of having successfully lured 20 plus people into unprotected sex knowing they are HIV positive’.

The deluded man goes on to make the ‘modest’ assumption that there are eight such people in each district and that if each of them infects 20 people who all go on to infect two more people, there will be many tens of thousands of people infected (although his calculations go a bit awry here). Even if Dr Ayiko is right in assuming that there are many people who behave this way and that they have many partners who also have many partners, HIV is not transmitted quite so fast. If it was, HIV prevalence would be a lot higher, in every country in the world, not just in Uganda. The partners of HIV positive people can remain HIV negative for many years, even if they are having regular, unprotected sex. HIV just doesn’t spread that quickly through heterosexual sex.

What the doctor needs to do is calculate how many times each of the 8 people per district would have had to have sex with the 20 others and how many times they would have to have sex in order to infect two others each, given the probability of heterosexual HIV transmission per sex act. That’s not a simple calculation and I won’t even attempt it here. But even if the probability is relatively high, each HIV positive person would have to have sex with each HIV negative person several hundred times for HIV to spread at the speed Dr Ayiko suggests. Deliberately spreading HIV is despicable, especially where there may be force or coercion involved. But deliberate spread of HIV through heterosexual intercourse would be a very slow process indeed. However heinous, it is not a major factor in Uganda’s HIV epidemic.

I would suggest to Dr Ayiko and others who support the Ugandan bill that purposely ignoring what could be the main modes of HIV transmission, non-sexual modes, is despicable. Not only is it despicable but some non-sexual modes of transmission, such as certain unsafe medical practices, are very efficient, far more efficient than sexual transmission. Worse still, the same people who have all the data and the epidemiological expertise that Dr Ayiko lacks are the ones who continue to ignore these modes of HIV transmission. UNAIDS, WHO, CDC and the rest of the HIV industry know that they are wrong about non-sexual HIV transmission in developing countries but they don’t admit it, for some reason.

Tim Allen notes the current dependency on large scale rollout of antiretroviral treatment (ART) as a possible remedy for HIV epidemics, despite the fact that we know so little about how these epidemics increase and decline. He warns that such dependence could give rise to widespread resistance, which could result in Uganda’s epidemic taking a serious turn for the worse. And it does seem sensible to find out how the epidemic progressed in the first place before climbing on the latest bandwagon, ART. In a country where it is not even clear how much medical treatment contributed to the epidemic, it seems rash to advocate purely for more medical treatment. There’s something of the black box about the HIV industry.

Many years of data on HIV prevalence, HIV knowledge and HIV behaviour show that these three are not very closely connected. People may know all the HIV industry want them to know about HIV but their behaviour is relatively uninfluenced by their knowledge. More to the point, their sexual behaviour is not very closely connected with HIV prevalence. Those who do all the things the HIV industry would like them to do often have higher HIV prevalence than those whose levels of unsafe behaviour would be deemed very high by the industry.

Indeed, sex workers in Kenya have been targeted for a long time. But the shockingly high prevalence found among sex workers in the 1980s, which peaked at 81% in 1986, fell continuously thereafter, falling below 50% in 1997 and remaining below this level. The amazing thing is that behaviour change didn't occur till a long time later. HIV and other sexually transmitted infections (STI) fell even though people didn't change their behaviour significantly. It simply became less likely that people in this group, said to be at high risk of becoming infected, would become infected with HIV or other STIs.

This is not to suggest that HIV is not sexually transmitted, just to remind people that it is not entirely sexually transmitted. But there is a surprising lack of clarity about how much HIV is transmitted sexually and how much non-sexually, especially in African countries with high HIV prevalence. It is clear that HIV can be and is transmitted by unsafe medical and cosmetic practices but it is not clear what percentage of HIV transmission is caused by such practices. The only thing that is clear is that the HIV industry doesn't want to admit that non-sexual HIV transmission is something to worry about in African countries.

So what is the HIV industry going to teach people, especially sex workers, in Chad? If they approach the problem in the same way that they did in Kenya, prevalence is unlikely to drop. It reached a peak of about 10% in Kenya in the late 1990s and even higher in Uganda some time earlier. But over a decade of 'HIV prevention' later, both countries have prevalence of over 6%. That's nothing to boast about. Will people in Chad be told the truth, rather than a little bit of the truth?

The truth is that people there are at risk of being infected with HIV by medical and cosmetic procedures. How high a risk is not really clear, it depends on how good the hospitals are and how many people have easy access to them. If there are few hospitals and few people go to them, they are probably less likely to be infected with HIV, though they could be more likely to suffer from and die from numerous other preventable and curable conditions. But people need to be warned that sexual behaviour is not the only risk.

I was in Nairobi a few days ago and I talked to several sex workers and, in common with many other people I have talked to in East Africa, they have heard a lot about sexual transmission of HIV. They have heard a little about the risk from intravenous drug use and only brief and infrequent remarks about risks from contaminated blood, such as during blood transfusions. But they are not told that they and their children could be at risk when they go to a clinic or to the hairdresser. Sex workers, especially, go to clinics a lot. They usually go to clinics that specifically target sex workers, where the risk of being infected with an STI would be higher than in clinics not targeting sex workers.

If people in Chad and other African countries are only told how to protect themselves from sexually transmitted HIV, they will not be very well protected. They also need to be told about non-sexual risks, unsafe medical and cosmetic practices. If they don't know about these risks they will not what measures to take to reduce the risks they and their families face. It would also be unsurprising if they continue to believe that they are at risk from mosquito bites and from sharing food.

As long as the HIV industry continues to insist that HIV is primarily transmitted by sexual behaviour in African countries and that other risks are not significant, a lot of preventable HIV infection will continue to occur. If medical facilities are risky for UN employees then they are also risky for Africans. It's hard to believe that the UN can have one story for Africans and another for their employees, but that seems to be the case at the moment.

Tuesday, June 22, 2010

UNAIDS, a well known publisher of glossy brochures written by highly paid professionals, have come out with one called "Agenda for Accelerated Country Action for Women, Girls, Gender Equality and HIV". It's a worthy sounding name and there's a lot of worthy stuff in it. UNAIDS recognises, to some extent, that more women than men are infected with and probably affected by HIV. The seem to accept that women are, for several reasons, more susceptible to HIV.

But for UNAIDS, the answer to every question about HIV assumes the truth of the 'behavioural paradigm', which holds that the bulk of HIV transmission in African countries occurs through heterosexual sex. Instead of asking why women are being infected with HIV in such high numbers in some places and such low numbers in other places, the document in question assumes that women are becoming infected because they are engaging in unsafe sex. Any action advocated to reduce HIV transmission is based on this assumption.

There were gender inequalities and human rights violations before HIV, and there will be after HIV is eradicated, if that ever happens. The fact that women become more susceptible to HIV as a result of these inequalities and violations is not a reason for objecting to them. The fact that they are gender inequalities and human rights violations is a reason for objecting to them. Equality and human rights are not just instrumentally good, they are good in themselves. Their absence is to be abhorred, regardless of the consequences.

People become infected with HIV by exposure to a virus. One way of becoming infected is by having sex with someone who is infected. Another is by some kind of blood exposure, such as sharing needles when injecting drugs. A third is through unsafe healthcare practices, a fourth is through unsafe cosmetic procedures and a fifth is when a fetus or baby becomes infected by their mother. To prevent HIV transmission, a number of precautions need to be taken, depending on the risks in question.

The UNAIDS 'action framework' focuses on three areas to contribute to HIV prevention: first, countries should 'know their epidemic and know their response' to meet the needs of women and girls. This means that a country should measure the exact contribution of unsafe sex to HIV prevalence. They should also know the extent of non-sexual transmission. But this document simply assumes that non-sexual modes of transmission are irrelevant. There are clearly some inequalities and human rights violations involved here but they are not the ones that are relevant to sexual transmission.

The document goes on to say that they (UNAIDS) and their partners will ensure that countries' strategies, plans, frameworks and budgets will address the rights and needs of women and girls in the context of HIV. But this is not so, they will only address rights and needs that pertain to sexual transmission of HIV. So all their 'Advocacy, capacity strengthening and mobilization of resources to deliver a comprehensive set of measures to address the needs and rights of women and girls in the context of HIV' will also be similarly limited.

There are many women who are mystified as to how they became infected with HIV. If they are not mystified, it's because they have been assured that they must have become infected by their partners. But some have had no partners. And others have partners who are not infected. UNAIDS, in this and other documents, assumes the applicability of the behavioural paradigm and concludes that almost everybody in African countries, male and female, was infected sexually. And then they go to great pains to say to women, who are infected in far greater numbers than men, that it is not their fault.

Women who are infected with HIV do not want to be told that it wasn't their fault that they had unsafe sex, that it's because they suffer from multiple inequalities and violations of their human rights. They don't want to be told how to protect themselves from sexually transmitting HIV when they are not engaging in unsafe sex and will not be in the future. The want to be told how to protect themselves from HIV, whether sexually or non-sexually transmitted. And if they are infected, they need to know how to protect their partner, their children and anyone else around them.

UNAIDS likes to use words such as 'participation', 'engagement' and 'decision-making', but this kind of documentation doesn't appear to have had any time for these concepts. They are not creating an 'enabling environment' or 'empowerment', rather, they are doing the opposite. They are brainwashing the world, and HIV positive women in developing countries in particular, into believing that HIV is mainly spread by heterosexual sex when it is quite clear that some transmission is by non-sexual modes. A genuinely 'evidence informed' and 'ethical' response would be to establish exactly how people are being infected and what contribution each mode of transmission makes in every country.

If UNAIDS are so concerned about gender inequalities and violations of women's human rights, they should do some genuine participative research in the field, rather than publishing pseudo-academic, platitudinous half-truths. HIV is a virus, a disease, it is a subject for epidemiologists, not moralists or politicians. HIV positive people are victims of the disease, not mere 'disease vectors'. If you want HIV to be seen as a disease and HIV positive people to be seen as victims of an epidemic, rather than being stigmatized and reviled, dump the behavioural paradigm. It's not all about sex.

Monday, June 21, 2010

There was a time when HIV was thought to affect men far more than women. That may be partly because it was first recognized in rich countries, where people infected were usually male and had sex with men. But it was soon accepted by the health care profession that both men and women could be infected, sexually and non-sexually. In developing countries, the number of women infected soon outnumbered the men. In Kenya, the ratio of HIV positive females went from 1:2.7 in 1986 to 2:1 in 2006 and it's probably about the same now, in 2010.

That makes HIV much more of a woman's disease than many others, even sexually transmitted diseases. The orthodoxy of UNAIDS, the WHO, CDC and others is that women are more susceptible, for various reasons, than men. But these institutions have been trying for years to say what it is that makes women more likely to be infected with HIV in developing countries than women in rich countries. They have come up with a lot of theories about African sexual behaviour, many of which are not borne out by the evidence. These 'theories' are mere prejudices in the absence of evidence, but they have been used to influence most of the HIV prevention activities carried out in high prevalence countries.

It's no wonder that most of these high prevalence countries have only seen small drops in HIV transmission. If there is no evidence for very high rates of unsafe sexual behaviour in high prevalence countries, and plenty of evidence for higher rates of unsafe sexual behaviour in low prevalence countries, the behavioural paradigm, the belief that most HIV transmission is due to high levels of unsafe heterosexual behaviour, is clearly faulty.

The behavioural paradigm was not so evident in the 1980s or even in the early 1990s. It arrived later, probably on the back of large amounts of donor funding from countries who chose, for political or religious reasons of some kind, to see HIV transmission as a moral issue. They chose to see high HIV prevalence as a sign that people in some countries were the victims of immoral behaviour and they switched their attention from non-sexual transmission modes to sexual modes.

The issue of institutional racism on the part of these institutions, UNAIDS, the WHO, CDC and others, has been raised on this blog before. The belief that Africans have higher levels of unsafe sex than non-Africans, when all the evidence says this is not so, lays the charge of institutional racism on their doorsteps. Never mind their posturing about wanting to reduce stigma or improve the lot of women.

But these institutions are also guilty of institutional sexism. Far from reducing stigma, the orthodoxy that says that HIV is mainly transmitted by heterosexual sex in developing countries stigmatizes women more than it stigmatizes men. How are HIV positive women supposed to see themselves in the light of this kind of orthodoxy? What options do they have to defend themselves from the implication that they are promiscuous? And how do they explain their positive HIV status to their husbands when they find that they are infected when their husband is not?

The orthodox view, the racist and sexist orthodox view, says that the majority of people infected, including the 53% of married HIV positive women, were infected by having unsafe sex of some kind. Some HIV positive women with HIV positive husbands are not even infected by their husbands because they are infected with a different genetic strain of the virus. All these women and men are tarred with the same brush, stigmatized by the very institutions that use public money, ostensibly, to reduce stigma, to reduce HIV transmission, to find out why HIV is being transmitted at such high rates in some countries and not in others.

We can offer HIV positive people in developing countries some hope of not being stigmatized. But only if we accept that the behavioural paradigm is wrong, that we don't yet know why people are being infected in such huge numbers. We can offer then a thorough investigation of the non-sexual modes of transmission, because this is clearly relevant. We just don't know the significance of non-sexual transmission yet and that is because we, or at least UNAIDS, the WHO and CDC, have steadfastly refused to investigate properly why HIV transmission is still so high in some countries. We behave like people who don't know anything about HIV transmission. But, in reality, we know the behavioural paradigm is a piece of racist and sexist nonsense.

Are we going to continue to allow people to become infected with a chronic and life threatening illness, even though we know that our policies are based on prejudice rather than on scientific knowledge? How do we face off the charges of institutional racism and sexism that we are so clearly guilty of? Or do we need to go through a process of truth and reconciliation, where the movers and shakers of the HIV industry are allowed to admit their abject failure and promise to eradicate racism and sexism from their institutions? This is not a time for professional, political or religious pride: until we admit we were wrong, we will continue to allow people to suffer and die.

Sunday, June 20, 2010

If Ireland, my country of birth, had a HIV epidemic like Kenya's, there would be 173,250 HIV positive people there, instead of 5,500. HIV prevalence in Kenya is estimated to stand at 6.3%, in Ireland it's 0.2%. Instead of having one HIV positive person for every 818 HIV negative people, Ireland could have one for every 26. Then it would not be unusual for every person and every family to know or be related to at least one HIV positive person, as is the case in Kenya.

Nyanza province, in the South West of Kenya, has a prevalence of 13.9%, twice that of the next highest prevalence, Nairobi, at 7%. But the Luo tribe, consisting of only around three million people, has the highest prevalence of any tribe in Kenya. At 20.2%, it’s over two and a half times the next highest tribe, the Maasai, at 7.9%. If Ireland had an epidemic like that of the Luo, there would be 555,500 HIV positive Irish people. Think of the dependency ratio and the health care bill.

I like to think that if that number of Irish people were infected with a chronic, life threatening illness, it wouldn't take long before it was established how people were becoming infected and measures were taken to ensure that transmission be reduced to as small a number as possible. I would like to think that the epidemic would be seen as an emergency far more significant than foot and mouth, bird flu, H1N1 and BSE all put together.

555500 is probably similar to the number of World Cup visitors currently in South Africa. The total number of HIV positive people in Kenya is about three times that number, or a third of the population of Ireland. And Kenya doesn't even come close to having the worst HIV epidemic in the world. South Africa itself is estimated to have well over 5 million HIV positive people. And prevalence in some countries, such as Swaziland, is even higher than that found among the Luo tribe.

But imagine if Ireland were to have such an epidemic, what would the government and various international health institutions say and do? Would they say that the epidemic was caused by promiscuity and that Irish people need to have less, or even no, unsafe sex? Would they say or imply that it was due to vague 'cultural' or 'tribal' practices? Or would they say it was due to low levels of circumcision? After all, circumcision levels in Ireland are low, as they are in all European countries.

And if many Irish people, either infected with HIV or affected by it, were to deny that they were promiscuous or careless, would they be believed? Would the government and various international health institutions investigate their claims and try to find out how they could have been infected if they were not infected sexually? If large numbers of infants and young children were HIV positive and their mothers were HIV negative, would that be seen as a possible indication that many of them, perhaps all of them, were infected by unsafe medical procedures or by some other non-sexual route?

A friend pointed out to me that the latest figures show that 53% of married HIV positive women in Kenya have HIV negative husbands. How did they become infected? Would the relevant authorities in Ireland, under similar circumstances, say or imply that these women were promiscuous, give them condoms and drugs and tell them to be careful in case they infect their husbands? Would they circumcise all their husbands as a priority?

Perhaps you would object and say that the scenario I present is futile and that the questions I raise are meaningless. Well, I'm tempted to agree. It seems brutal to ask if the world would be indifferent to the plight of such huge numbers of people, of whole nations, of a whole continent. Could health, economic and political professionals be so inhumane as to humiliate sick people and refuse to protect those who are, as yet, uninfected?

The number of people newly infected with HIV every two years globally is about the same as the population of Ireland. HIV has been recognised for nearly three decades. Since it was first identified, it was clear that it was transmitted, not just sexually, but also through contaminated blood and bodily fluids and by mothers to their infants. After HIV was identified, various measures were taken to reduce transmission, whether transmission was sexual or non-sexual.

But now, people here in Kenya seem almost unaware of any threat aside from that of unsafe sex. Many people, on finding they are HIV positive, assume they must have been infected sexually because that's what they are told, over and over again. They have not been told how to protect themselves from unsafe medical or cosmetic practices, only that they should abstain, be faithful and wear a condom, three things that will never protect them from non-sexually transmitted HIV. It's no wonder people think they must have been infected by mosquitoes or by someone putting a curse on them.

Perhaps the eminent people of UNAIDS, CDC, WHO and other institutions would like to tell the president of the US that many members of his father's extended family and fellow tribespeople are HIV positive and that this is so because most of them are extremely promiscuous and that they need to stop having sex, start using condoms and get circumcised if they are male. Because that’s what they are telling Obama’s father’s people. So perhaps this is what they would say to Irish people under the scenario I mention above.

I would like to think that this would not be their reaction, but what evidence is there that their reaction would be different? Because I don't believe that there has ever been a sexually transmitted disease that has spread like HIV is said to have spread among the Luo people or among the Swazis. I'm not sure if such a sexually transmitted disease is even possible, I certainly hope not. But if HIV prevalence among the Luo and among other populations exceeds our worst nightmares, why is it not considered to be the emergency that it clearly is? I'm not asking why HIV spreads as fast as it does but why it spreads so fast among some people and not among others. And please don't tell me that it's because Luos are 100 times more promiscuous than the Irish.

Friday, June 18, 2010

Having looked at some of the figures for HIV prevalence in Kenya collected in 2007 and published earlier this year, I was not expecting another set of figures to come out so soon. But the 2008-09 Demographic and Health Survey (DHS) was released recently, so it's worth looking at some of these figures.

Since the 2003 DHS, prevalence has fallen slightly, from 6.7% to 6.3%. The major falls were in Nairobi and Coast provinces, though prevalence also fell in five other provinces. The only province that saw an increase was Western province, which went from 4.9% to 6.6%. This is good news, given that the 2008 Kenya Aids Indicator Survey (figures collected in 2007) found that prevalence had increased overall.

HIV prevalence in Kenya has always been higher in urban than in rural areas. However, the trend is for the share of infections in rural areas to increase. And as the vast majority of Kenyans live in rural areas, the number of people living with HIV in rural areas has long been higher than the number in urban areas.

The ratio of female to male infections overall has remained steady, at about 2 females for every one male. But in most provinces, this ratio has altered considerably. In Eastern province, for example, the ratio went from 4 women to every one man in 2003 to 4 women to every 3 men in 2008.

Despite the epidemic affecting women far more than men, there is still a lot of emphasis on the presumed effectiveness of male circumcision. This is said to give men some protection from HIV, though little or none to women. However, the mass male circumcision campaign in Kenya concentrates on only one of the three tribes in only one of the eight provinces, the Luo tribe of Nyanza. This makes the finding that "Luo men who are circumcised have roughly the same HIV prevalence as Luo men who are uncircumcised (16 percent compared with 17 percent)" rather shocking.

A campaign by CDC (US Center for Disease Control) aims to circumcise in excess of one million Luo men in the next year or so. I wonder how much they have told the men about this sort of finding.

The assumption that HIV is almost entirely transmitted sexually, especially by 'high risk' sex, is as pervasive as ever. That assumption is challenged by some of the findings, without being modified in any noticeable way. For example, in Table 14.7, relating to HIV prevalence by sexual behaviour, females reporting no sexual intercourse in the last 12 months have higher prevalence than those reporting 'higher risk' intercourse.

HIV prevalence was twice as high in females who reported sometimes using a condom (16%) than in those who reported never using a condom (7.8%). It's hard to know what is going on here but one thing is sure: if condoms were so ineffective in Western countries, there would be a thorough investigation. How can people be more likely to be infected if they use condoms? The Catholic and other Christian Churches should be happy as they have long preached against the effectiveness and morality of condoms. But if there is a question mark over both circumcision and condom use, how does Kenya now propose to reduce HIV infections?

It is hard to maintain the assumption that HIV is mainly transmitted sexually in Kenya without at the same time assuming that women must be far more promiscuous than men. There is no independent evidence showing that African women are more promiscuous than African men or that Africans are more promiscuous than non-Africans, for that matter. But over and over again in these figures women and girls, from a young age, are infected in much higher numbers than men. Assuming that these women are infected by men, where are all these men? Unless there is a small number of men who do most of the infecting and most of these women are having sex with them at some time, the HIV epidemic in Kenya is hard to understand.

There are figures that may support the contention that HIV is mainly transmitted sexually. For example, in both men and women, those with a history of having a sexually transmitted infection (STI), or symptoms of one, are twice as likely to be HIV positive as those who have not. But this could also suggest that people attending STI clinics are being infected with HIV through unsafe medical practices.

Indeed, the possibility of unsafe injections as a mode of HIV transmission is mentioned twice in this 455 page report. The fact that some people who are HIV positive reported never having had sex raises this possibility. But it is tempered by the possibility that sexual experience can be underreported, which it can. It can also be overreported. But will this lead to an investigation into why some people who say they have never had sex turn out to be HIV positive? I can't imagine such a finding not being investigated in a Western country.

If there are people who have been infected non-sexually in Kenya, and it's highly unlikely that there are none, this needs to be investigated. Because people who are sexually active can also be infected non-sexually. There has not been a proper investigation in Kenya into what proportion of HIV is transmitted non-sexually. The assumption that HIV is predominantly transmitted sexually has shaped HIV intervention policy and this policy appears to be failing. HIV prevalence has stayed at about the same level ever since the high death rates of the early 2000s have gone down.

Another area for enquiry is the large number of men who are infected whose partners are not and the large number of women who are infected whose partners are not. We can't just assume that they have all been infected because they are promiscuous, especially when they say they are not. Even where both male and female partners are infected it can turn out that they didn't infect each other. People are being infected with HIV and they have no idea why. The authors of the DHS have no idea why, either. HIV transmission will not be eliminated or even reduced substantially until we understand exactly how people are being infected.

There is no shortage of evidence showing that the behavioural paradigm is wrong; we cannot explain high rates of HIV prevalence in Kenya and other African countries on the basis of higher rates of 'risky' sexual behaviour. Research has shown that, on the contrary, high rates of the sort of sexual behaviour thought to be most risky are more likely to be found in Western countries, where HIV prevalence is low. If HIV is not only transmitted sexually, we need to establish how else it is being transmitted, to what extent and how best to eliminate these modes of transmission.

The Kenyan health departments claim that the law in question was pushed by the Ministry for Industry, who didn't realise the implications of the wording of the law. Both these claims sound suspect and the whole issue of a bill which was so stacked in favour of the pharmaceutical industry and against the generic drug industry smelled of industry lobbying and arm twisting. And in practice, even without this law, enormous amounts of money are spent on non-generic, branded products, despite the availability of generics that cost a fraction of the brand price.

Most money spent on health in Sub-Saharan African countries comes from donors. This is one of the reasons that unnecessary amounts of money are spent on overpriced branded drugs. African countries certainly couldn't have afforded them. Some even suspect that a lot of foreign donor money is specifically made available for branded drugs in order to destroy the generic market. After all, branding, intellectual property, is a particularly egregious form of market protection. And there are few who like to protect their markets more than the pharmaceutical industry, regardless of how many people suffer or die from treatable and preventable illnesses as a result.

Many other African countries followed Kenya's unwise decision to pass intellectual property law that only benefited pharmaceutical multinationals, so maybe some of them will reconsider this now. Perhaps they will also get behind MSF and any other organisations involved in campaigning for fair economic conditions for developing countries. Tanzania and others are wondering how they will fare now that so much donor funding has been cut, with the global economic crisis being used as an excuse. They will do a lot better when they exercise their right to purchase generic drugs, rather than wasting the ample HIV funding on extortionately priced brands.

Multinationals and other pushers are constantly bleating about how people in developing are suffering and all rich country governments need to do is pay for their products for things to be ok. But there just isn't enough money to buy branded products, nor is there any necessity to do so. Much of the current HIV transmission in developing countries is preventable, especially transmission from mother to child. But despite the relevant drugs being available for many years, an estimated 43,000 babies were infected by their mothers in Tanzania in 2008 alone. Of the 217,704 new infections, many more would have been the result of lack of proper equipment for ensuring proper levels of medical safety. Tanzania need to find affordable drugs and medical equipment so that they can get by with less money.

The issue of intellectual property protectionism goes far beyond essential drugs and medications. Most household product markets in Kenya and other African countries are dominated by one single brand or a handful of brands, for example, soap, sanitary pads, diapers, cleaning materials, etc. These brands are unnecessarily expensive but one disinfectant soap manufacturer even claims that using their soap makes you and your children 100% healthier. Such claims, leading people to believe that they are harming their families if they don't use these products, are widely advertised. That is where much of the money made by multinationals is spent; it's spent on marketing and advertising, not on research, as they would like us to believe.

Let multinationals do their own dirty work, they should not be entitled to donor money that is supposed to be spent on needy people. If these organisations are bothered by competition from generics, let them put their prices down and learn how to compete, for a change. They love talking about competition but they usually operate in completely protected environments. And if they think those producing fakes are worth fighting, they could just lower their prices enough so that it is no longer worth while producing fakes. Fakes are only economic when the cost of making the goods is low but the price charged is high. Multinationals should start abiding by some of the principles they seem to think are so important. They have priced themselves out of the market that they have worked so hard to rig in their favour.

Countries like Kenya and Tanzania are right to be worried about reduced funding but there are two things that may work in their favour. Firstly, if they are less dependent on donor funding, they may be better able to shop around for affordable drugs and other vital goods. At present, donors usually decide which drugs and goods to purchase and they favour their own markets. That's what being a donor is all about, isn't it! Secondly, they may find ways of achieving even more with less money once they are freed of all the restrictions that foreign loans and donations often carry. This is not an argument for reducing funding, which I think should be increased. But it is an argument for funding to become more transparent, more democratic, more like genuine funding than merely a tool for benefiting the donor far more than the recipient, as it appears now.

Tuesday, June 15, 2010

Those in the Aids industry often talk about gender and empowerment in relation to reducing HIV transmission. But what do they mean? Do they mean that women would be able to protect themselves from HIV if only their rights were recognised, such as the right to decide when, where, with whom and under which circumstances to have sex? Well, gender inequality is repulsive in many ways and it has numerous negative consequences. Gender equality is a human right and we should strive for full gender equality everywhere and remove barriers to equality.

But in developing countries like Kenya, people face all sorts of risks that make them vulnerable to diseases, not just HIV. And the risk of sexually transmitted HIV is higher where women don't have rights to negotiate or determine their sexual or reproductive life. The Aids industry seems anxious to inform women about these rights but they don't seem to regard women's rights to safe healthcare as being important, or as having any relevance to their sexual or reproductive life. These issues only merit brief mention every now and again. I read or scan through hundreds of articles every week and rarely come across one that even mentions the non-sexual risks of HIV.

To repeat myself, gender inequality is repulsive and such inequalities are probably involved in transmission of all sorts of disease and exposure to many risk factors, such as lack of access to clean water and sanitation, adequate housing and a clean environment. But gender inequality itself does not transmit HIV. HIV is a virus transmitted from person to person, through sexual intercourse, by HIV mothers giving birth or breastfeeding or through unsafe medical or cosmetic procedures.

It may sound like hair splitting, but people will continue to have sex (I presume) even if gender inequalities are reduced, they will continue to have children and they will continue to avail of medical and cosmetic procedures. Ensuring that women have the right to choose the circumstances under which they do these things is all very well, but what sort of choices are women going to make when, firstly, they don't know anything about unsafe medical and cosmetic practices and secondly, they have no influence on how those practices are carried out or how to make them less risky?

The truth is that the Aids industry is very much in the dark about how HIV is transmitted in most countries. They know that medical and cosmetic transmission occurs but they have not investigated instances of these kinds of transmission. They have chosen to concentrate on sexual risk to the exclusion of all other risks. They have made a choice about the health and welfare of people, especially women (who are exposed to far more healthcare and cosmetic risks than men), that disempowers women in developing countries. By deciding what risks women need to avoid and ignoring others, the Aids industry is doing the opposite to what it says: it is beating the empowerment drum while silently spreading disempowerment.

Incidentally, the HIV 'gender imbalance' in Kenya is quite curious in many ways. North Eastern province has the worst Gender Development Index (GDI) but also the lowest HIV prevalence. This province also has the highest percentage of girls married by the age of 18. The province with the lowest percentage of girls married by age 18 and one of the best GDI figures, Nairobi, has the second highest HIV prevalence.

Looking at it another way, in Central and Eastern provinces there are four HIV positive women for every one HIV positive man. These two provinces have little in common, with Central having the best set of development indicators and Eastern having one of the worst. Central province has only half the HIV prevalence rate of the country as a whole but Eastern has only a third, in other words, very low HIV prevalence. According to the received Aids industry view, somehow, a small group of men manage to infect a very large group of women. What, exactly, is the Aids industry saying about the sexual behaviour of people in these provinces?

Compared to that, there are only two HIV positive women for every one HIV positive man in North Eastern and Rift Valley provinces. As you move to the provinces with 'more equal' HIV epidemics, where there are only 1.5 HIV positive women for every HIV positive man, you find that these three provinces all have relatively good GDI scores but they account for half of the HIV positive people in Kenya. The Aids industry may interpret this as showing that sexual behaviour in these provinces is not as risky as that in some other provinces. Yet this lower level of risk seems to give rise to much higher rates of HIV transmission.

The oddest ratio of all is found in Coast province, where there are only 1.3 HIV positive women for every one HIV positive man. This looks more like a truly sexually transmitted disease, where male and female prevalences are similar enough. But this is also the province where there is likely to be the highest rates of intravenous drug use (mostly men) and sex tourism (which doesn’t seem to result in large numbers of HIV positive tourists). Even men having sex with men is said to be high here but I don't think that is borne out by the evidence. But is this infection ratio really a reflection of sexual practices here being quite different from those in other provinces? It would be difficult to say without investigating, not just sexual practices, but also any other ways in which HIV could be transmitted.

HIV transmission patterns are very complex and vary a lot, even within a country like Kenya. Gender is, of course, relevant. But perhaps it's not relevant for the reasons the Aids industry wants us to believe. There is little to be gained by patronising campaigns that tell women how hard their lives are but that also ignore the very risks that could most easily be avoided. Gender inequalities don’t just relate to people’s sexual behaviour, they relate to people’s access to healthcare, education and other social goods. Gender inequalities also relate to the sorts of information that people have access to. The Aids industry currently ensures that women don’t have access to adequate information that would allow them to protect themselves and their children from HIV and other diseases.

Women can be empowered and stigma can be reduced at the same time by accepting that HIV is not just transmitted sexually. To work out what proportion of HIV is transmitted sexually and non-sexually, the Aids industry needs to stop obsessing with people's sex lives and further humiliating them. The industry needs to investigate the numerous women who are HIV positive when their partners are HIV negative and the numerous children who are HIV positive but who were probably not infected by their mothers. Simply telling people that being HIV positive is not their fault while making it clear that you think it probably is their fault is not going to help people to avoid HIV risks or to reduce stigma.

Bandying about words like 'gender', 'empowerment' and 'stigma' is not going to reduce HIV transmission as long as non-sexual HIV transmission is left out of the picture. At present, the strategy of the Aids industry simply disempowers people and increases stigma. Don't just pat people on the head and tell them it's not their fault, show them how HIV is being transmitted and how they can protect themselves and others.

Sunday, June 13, 2010

I searched in vain for any mention of the risks of non-sexually transmitted HIV before the World Cup. But all the big news sources, CNN, BBC, Al Jazeera, along with lots of newspapers and news sites, covered sexual transmission of HIV, exclusively. They warned people about unprotected sex and using condoms, etc, but none of them warned people that in South Africa, medical and cosmetic treatment can carry huge risks from unsterilized equipment and unsafe procedures.

This is particularly odd because I would put money on it that these same organizations warn their own employees about non-sexual dangers. I could be wrong, perhaps they don't warn their own employees. But many big organizations do, such as the UN, WHO and CDC. Even an MSF Kenya employee I talked to recently said she and her colleagues wouldn't use local medical or dental facilities (though, inexplicably, she didn't seem to think medical transmission posed much of a risk to people who lived in the country). So big media are either guilty of the double standard of warning their own employees of a risk that everyone in African countries face without warning African people; or they are guilty of negligence in not warning their employees about this serious risk.

Of course, they may have been advised by UNAIDS or the like that medical treatment does not pose much of a risk. What they mean by this is that they are currently admitting that in excess of 5% of HIV is transmitted by medical treatment. These thousands of people infected are so insignificant that UNAIDS deems it better to keep talking about sexual transmission and completely ignoring medical transmission because otherwise, people might not have confidence in their medical service providers. So, is there a risk or is there not?

If the risk is so small, only a few tens or perhaps hundreds of thousands of new cases every year, why not warn people about it? Because if the risk is small, they shouldn't be unduly worried about their medical service providers. But then, if the risk is small, why do UN agencies warn their own employees away from using medical services in African countries that are not approved by the UN? And while in excess of 5% of cases may not seem so significant to UNAIDS, that's 8 or 9 times higher than the contribution of medical treatment to HIV prevalence claimed for Kenya, which the same UNAIDS put at about 0.6%.

What is so wrong with saying that people face risk from both sexually transmitted and non-sexually transmitted HIV? Is it so hard to admit that when millions of needles and other sharp objects are stuck into people every day, some diseases may be accidentally transmitted? Because, if UNAIDS had the balls (or do I mean teeth?) to admit this obvious possibility, people living in African countries would be in a position to do something to protect themselves, perhaps even to lobby their governments to change things so that they don't face these dangers.

I think UNAIDS are right, if people found out that they or their children face an appreciable risk of being infected with HIV, they would think twice before having routine medical treatment. But what would UNAIDS prefer? That tens of thousands of preventable HIV infections continue to occur because they think that number is insignificant compared to people suspecting that their medical service providers are not very safe?

Either the danger of medical transmission is insignificant, and then it shouldn't be beyond the capability of UNAIDS and their chums to manage the fallout from telling the truth: that there is some danger. Or medical transmission is anything but insignificant, in which case UNAIDS and all other relevant agencies should lose no more time in warning people of the risks and in mitigating those risks so that people can return to their medical service providers with greater confidence.

I don't accept that it is better to keep people in the dark and allow some of them to become infected with HIV when this is completely avoidable. I don't accept that it is better not to tell people how to protect themselves or to try to cover up the danger on the grounds that people not using medical services is a bigger evil. African people are being treated like idiots, who don't know how to evaluate risks and to take measures to avoid them.

It looks as if people visiting the World Cup are being treated the same way, being told to avoid sex or to use a condom. Some of the more self righteous in the HIV industry like to say that the only way to be 100% sure of not contracting HIV is to abstain from sex. But this is not true. Abstaining from sex has not protected the thousands who have been infected non-sexually and the thousands more who will continue to be infected because UNAIDS, in their great collective wisdom, don't wish to inform people that there are also non-sexual risks that abstaining from sex and wearing a condom won't protect you from.

What is so difficult about telling the whole story, that HIV can be transmitted sexually and non-sexually? And if UNAIDS can't be trusted to do so, why is it so difficult for news agencies to do so? Do they really all care that little about HIV continuing to spread, unnecessarily? Or are they just so obsessed with sexual behaviour that only sexual risks are considered worth reporting?

Thursday, June 10, 2010

I'm not just suggesting that UNAIDS have failed to reduce HIV transmission to the extent that the epidemic will be wiped out in the foreseeable future, although they have certainly failed to do this. I'm suggesting that they seem content to allow HIV to spread, especially in developing countries, as long as it is not transmitted sexually.

This is disingenuous because people who are not infected with HIV sexually, for example, if they are infected though medical treatment or cosmetic treatment, can still go on to infect others sexually. It is not possible to significantly reduce sexual HIV transmission without also reducing non-sexual transmission. It is also rather pointless to target sexual transmission and exclude non-sexual transmission completely.

The question is, why does UNAIDS see its mission as relating almost entirely to sex? In the early days of Aids, before the exciting prospect of a UN agency entirely devoted to one disease was even recognised, non-sexual transmission of HIV was still considered important. Warnings about HIV risk included risk of medical transmission and risk from other procedures that involved possible blood borne transmission.

As a result, Western hospitals changed the way they did things, especially relating to any procedures involving possible blood exposure. Blood transfusions represented one of the greatest threats and even developing countries now have policies relating to transfusions that are estimated to have cut this form of HIV transmission considerably, perhaps completely.

But developing countries have not had the resources or the training to improve their health facilities enough to convince the UN, and probably many others, that they are safe. And indeed, they are not safe. Westerners travelling to developing countries, especially in Africa, are often warned about medical and other treatment that could carry the risk of exposure to HIV and other blood borne diseases. But Africans are not warned.

An unusual exception to the practice of warning Westerners (and not bothering about people in developing countries) seems to be occurring at the moment. I don't think people visiting South Africa for the World Cup are being warned about non-sexual risks, although they are hearing plenty about the sexual risks. Some of them will probably feel they have had enough sex by the time they get to South Africa. Others may only feel their appetites whetted.

69,000 children infected in one year! What are the possibilities? That their mothers are all HIV positive (the report authors say it is unlikely that these are linked to mother to child transmission)? But many (not all, unfortunately) HIV positive mothers receive treatment to prevent transmission to their infants. And even among those who don't, HIV transmission is not 100%. There are other possibilities, but certainty is needed. When a country has tens of thousands of HIV positive children, this needs to be investigated, so we can be sure what is going on. If you were the parent of one of those children, would you accept UNAIDS contention that most HIV is transmitted sexually?

Being black in South Africa means you are 9 times more likely to be infected than if you are from any other race. Being from Mpumalanga province means that you are 12 times more likely to be infected than if you are from Northern Cape. And if you are from an urban slum, you are over 5 times more likely to be infected than if you are from an urban non-slum area. If you are from a rural area, you are far less likely to be infected, regardless of whether you are from a slum or a non-slum.

Females between the ages of 20 and 29 are over 6 times more likely to be infected than males of the same age group. Just in case these figures suggest that the predominantly well off male and younger visitors to the World Cup could be at an advantage, they will be mainly in urban areas and if they happen to visit medical or cosmetic outlets, the contaminated blood they are exposed to could have come from a male or female of any age or race and from any location.

Also, rates of new infections among people who reported never having sex or who reported not having sex in the past 12 months stood at 1.5% and 2.4%, respectively. This could represent tens of thousands of people whose HIV infection probably came from a source other than sex. Where did their infection come from? From being African, according to the UNAIDS received view; they have simply underreported their sexual behaviour, in other words, they lied.

So, if you are visiting South Africa and you end up in bed with someone you meet there, you would be crazy not to wear a condom, just as it would be crazy in any other country in the world. You would be better off avoiding sex altogether, if that is your favoured way of reducing the risks you face for HIV, unplanned pregnancy and other sexually transmitted infections.

But you are not protecting yourself adequately if you think that having sex is the only way of becoming infected with HIV. You may well be safe enough if you take the right precautions, no matter who you sleep with. But you will be in far greater danger if you have to go to a hospital, a dental surgery, a tattoo parlour or a hairdresser.

If soccer fans visiting South Africa are lucky enough to be able to choose the health facilities and other service providers they visit, that's great. But South Africans will not be so lucky. As long as UNAIDS insists on playing the sexual card, people will remain in the dark about non-sexual risks. Providers of health and cosmetic services will continue to use unsafe procedures and people will continue to be infected with HIV.

Now that fifa and other commercial interests have their snouts firmly in the trough and journalists have been distracted by one of their favourite subjects, sex, UNAIDS is unlikely to take the only sensible route of warning people about both the sexual and non-sexual risks of HIV. As to why they have so far refused to accept that non-sexual transmission of HIV plays a significant part in the HIV pandemic in Africa, that is anyone's guess. But people are being infected, they are suffering and dying, unnecessarily. Why does UNAIDS receive public money to behave in this way?

Wednesday, June 9, 2010

In the run up to the World Cup in South Africa, the excuse for talking exclusively about sexual behaviour and HIV risk and ignoring any other risks, such as the risks of medical transmission, seems to be that sexual transmission is the most common form of transmission in African countries.

The view that sexual transmission is so common that non-sexual transmission is almost negligible is debatable and the official figures are based on guesswork rather than proper research. But even if the figures were correct, it would be stupid to ignore non-sexual risks just because sexual transmission is more common.

Driver error may be a common cause of road traffic accidents but I wouldn't want to ignore the fact that my breaks are worn out just because it is a less frequent cause of accidents.

We know that the UN worries about medically transmitted HIV enough to warn its own employees about it:

So why not warn soccer fans and other visitors to South Africa and other African countries? More importantly, why not warn all Africans, most of whom have no option but to use their medical facilities, no matter how inadequate they are?

Sure, international health institutions want people to trust their health facilities enough to get medical treatment when they need it, to get tested for things like HIV and to take the advice of health professionals. But is that a reason to deceive the public?

The public might be afraid that official sources are lying to them or that they are keeping something back. But official sources are lying to them and keeping something back. All over Africa, there have been clear outbreaks of medically transmitted HIV. These have been covered up or just ignored and no investigations have been carried out.

Even if only a handful of HIV infections were caused by medical transmission, people should be made aware that the possibility exists. They should be in a position to protect themselves, to insist on sterilized equipment and other safe practices. If they don't even know that unsafe medical procedures occur, they will not know that they need to protect themselves.

But there is little question about whether medical transmission of HIV is common in African countries. Medical facilities have long been underfunded, understaffed and otherwise inadequate. It would be more surprising if very few transmissions of HIV occurred than if a sizeable number occurred. The only question is about how common medical transmission is compared to sexual transmission.

In the long run, people will have more confidence in public health information and in public health facilities if they are told the truth now. Those trusted to provide people with the information they need to stay healthy are not presently entitled to that trust. Maybe people will question the safety of health facilities once they realise that things have been kept from them. But as things stand, they are right to ask questions.

If it is risky for UN employees to trust medical facilities that are not approved by the UN, it is also risky for soccer fans. And if it's risky for visitors to Africa to mistrust medical facilities, it is also risky for Africans. No amount of abstinence, faithfulness to one partner or condom use will protect people from medically transmitted HIV. HIV can be, and often is, transmitted by medical and dental treatment and by cosmetic treatment such as tattooing, piercing and hairdressing, in African countries. It is not just transmitted by 'unsafe' sex.

Tuesday, June 8, 2010

Since writing about HIV and the World Cup in the last few days, I have looked for news outlets and the like for coverage of non-sexual HIV risks that people visiting or living in South Africa face. I found nothing. A couple of sites mention needle sharing as a potential risk but the tone of the warning suggests that it is aimed at intravenous drug users. There is no mention of the risks of visiting a dentist, a doctor, a nurse, a surgeon, a tattoo artist, a hairdresser or any other non-sexual risks. Can journalists and others trying to squeeze all that they can out of the World Cup not find space for a brief mention of these issues?

The remarkable thing about medical transmission of HIV in African countries is not that it doesn't happen. It's that no investigations have been carried out when medical transmission has clearly occurred or where it may have occurred. Infants, children and even adults who have had no sexual exposure are HIV positive, yet there have been no calls by international health institutions, African governments or HIV donors for investigations. In most African countries, the number of women infected far exceeds the number of men infected. And though women's groups fall over themselves to get their issues heard, they don't seem to be outraged that women seem to comprise the largest number of victims of medically transmitted HIV.

Endoscope and biopsy equipment were found to have been insufficiently sterilized after nine patients became sick. There was also a contaminated anaesthetic involved. These are problems that African hospitals face all the time. They often don't have the equipment to sterilize everything properly, nor even enough trained staff to carry out the work. African hospitals also have the problem of old equipment, shortages of equipment and the need to reuse things that are designed to be disposable. Health workers are not going to do without gloves just because there is a shortage. How many options do they have?

In Australian hospitals, people are far less likely to be infected with HIV, hepatitis or other serious illness. But in African countries, where only the sickest go to hospital and many serious diseases are endemic, the risks are very high. But patients becoming ill after receiving medical treatment in African hospitals is so common that this is unlikely to trigger any kind of investigation, as happened in the Australian instance. And if people die, there are unlikely to be any questions asked. Many people die every day of all sorts of things. Health workers have little enough time to deal with sick people, let alone dead people.

But I know that the parents of most children here would have no idea that needles and other hospital wastes carry a risk of infection with HIV and other diseases. Some people can tell you that sharing needles and the like carries a risk but most have not been fully warned about the risks associated with medical and cosmetic facilities. Indeed, the official line is that there is only a tiny risk from medical and cosmetic transmission of HIV. Those responsible for the official line, UNAIDS, WHO, CDC and the rest, must be well aware that non-sexual risks are far higher than they admit. But for some reason, they don't want Africans to know that these risks exist and, consequently, how to protect themselves.

And so, as the Western world worries about Westerners going to the World Cup being infected with HIV through some kind of sexual encounter, it's quite amazing that there are no warnings about non-sexual risks. Football supporters don't just like drinking and having sex after matches, they also like fighting, especially when their team loses. And drunk people can be prone to all sorts of accidents. People will end up in accident and emergency wards, dental surgeries and the like. People also may like to get that special football tattoo in South Africa, where it may be cheaper, but also more dangerous.

No doubt, there will be the usual slew of stories after the event about how various efforts and initiatives failed and how things should have been done differently. Journalists will never close the stable door if they can make a story about the bolted horse. So if the media, websites, officials and other sources of information will say nothing about non-sexually transmitted HIV, instead concentrating exclusively on sexual transmission, there will also be stories about how people are let down by health services and how unhygienic tattooists, hairdressers and ear piercers are. But only when it is too late for the victims.

If the Western press is really so worried about the health of Westerners, they should highlight the risks of non-sexually transmitted HIV and other health risks that people receiving medical and cosmetic treatment in South Africa face. They clearly are not worried about the risks that South Africans face and will continue to face after the World Cup has ceased to be front page news. But there is hope that South Africans themselves will one day question the official line, that they have so much sex that this explains why the country has more HIV positive people than any other. South Africans themselves may question the state of the health services that are available to them and ask why they have not been warned about non-sexual HIV risks or how to protect themselves. This is a very good time for them to raise these questions, before the Western press goes back to seeing Africa as a far away place populated by foreigners who have a lot of risky sex.

Monday, June 7, 2010

It's all about taking part, not winning, right? It’s certainly not about corporate domination, making money or anything so sordid. The World Cup probably means different things to those who care, can afford it or have something to gain from it. But there seems to be a worry that warnings about public safety could detract from people’s enjoyment of the football. According to the British Guardian, Fifa are blocking attempts to distribute condoms at venues. Fifa deny this and say no attempts have been made to set up condom distribution facilities. But even safe sex information has been banned, apparently.

I imagine people from Western countries travelling to South Africa will receive plenty of information about safe sex before they leave their own safe countries. Many will probably have their own supply of condoms or be able to buy them on arrival. They may even receive information on other HIV risks, such as from medical and cosmetic treatment.

They may be told that some health providers have a shortage of equipment and trained personnel, so they have to make sure that needles, syringes, suture needles and other equipment are properly sterilised if they haven’t taken a supply of medical equipment with them. It’s possible that visitors will also be warned to avoid getting tattoos, body or ear piercings or any cosmetic treatment that breaks the skin. (I’ve seen a warning about avoiding tattoos because they may be regretted later but none about the risk of HIV or any other disease.) Condoms are great for preventing sexual transmission, but I think people will need information about more than just basic safe sex.

Some Aids organizations are said to see the World Cup as a good opportunity to give out messages about HIV. But which messages are they trying to give out? That HIV is sexually transmitted? Report after report has shown that most people in African countries already know that. Whether people from Western countries know that or see that as relevant to them is another matter. But when will Aids organizations start to warn people about non-sexual risk of HIV? Non-sexual risks, especially from medical treatment, have been recognised since the early 1980s, almost since HIV was identified as the virus that caused Aids. But since early on in the epidemic, international health institutions have remained relatively silent about this important mode of infection. It is rarely discussed and every year these institutions publish figures purporting to show that medical transmission is very low and hardly worth worrying about.

Hospitals in South Africa are generally in poor condition, places you would not visit for treatment unless you really had to. Most South Africans really have to put up with these conditions, but rich South Africans (and rich visitors) don’t. They can opt for the expensive and hopefully safer hospitals, such as the ones that are looking for health tourists during the World Cup. Even those World Cup fans who need routine accident and emergency treatment will probably opt for something a bit better than the facilities available to poor South Africans. If Aids organisations see the World Cup as an opportunity to get a message across, that message should be relevant to everyone, regardless of their race, economic circumstances or any other criterion.

It is clear that HIV is transmitted by routes other than sexual behaviour. It is also clear than non-sexual transmission is far higher than UNAIDS and others will admit. Just how high non-sexual transmission goes in African countries is unclear because outbreaks of medically transmitted HIV have, so far, been entirely uninvestigated. UNAIDS is happy to warn UN employees to avoid medical treatment in African countries, except in UN approved hospitals. But they don’t seem to want Africans to know about the risks of medically (and cosmetically) transmitted HIV. This is the message that needs to be broadcast during the World Cup. Why the sudden worry that a few Westerners will become infected with HIV when Africans are being infected every day and much of this transmission could be avoided?

A brief article about preparations for medical emergencies during the World Cup mentions the ‘beleaguered health system’ and the huge HIV epidemic, but says nothing about the risk of medical transmission of HIV. The country is not suddenly going to acquire the capacity to provide adequate and safe medical treatment for everyone, no matter how important the World Cup is perceived to be. But that is part of the important message that Aids organizations should be concentrating on: that people should be aware of all the risks and how to protect themselves in order to avoid HIV and other diseases. The warnings should no longer be just about sexual risk but should include non-sexual risks too, especially risks of medical transmission.

The sort of racism that gives rise to UNAIDS and other institutions claiming that HIV is mostly transmitted by heterosexual sex in African countries results in an overemphasis on sexual risk and little or no emphasis on medical transmission. But another instance of racism seems to come out in the run up to the World Cup. There seems to be a lot more concern about non-Africans becoming infected with HIV than about Africans, who face risks, sexual and non-sexual, every day. They have faced these risks for decades and it looks as if they will continue to do so for decades. Apartheid may have ended, nominally. But every African, as well as every non-African, needs to be aware of how to avoid HIV infection and everyone needs access to information and facilities that will protect them. These are not yet available: that is why around 1,400 South Africans become infected with HIV ever day. HIV risk didn’t start with the World Cup and it won’t end with there. But it looks as if the usual Aids organisations will waste the opportunity by talking exclusively about sexual risk, yet again.

Thursday, June 3, 2010

Many people who follow the HIV pandemic will be looking with interest at the soccer in South Africa or rather, reports about possible HIV transmission there. There are claims that tens of thousands of women from around the world are flocking to South Africa to work in the sex industry and that a lot of soccer fans will be availing of these services. Whether these claims are true or not is anyone's guess, I've seen no evidence to back them up.

It seems likely that even if people visiting South Africa don't know how to protect themselves, those working in the sex industry will. One hopes so, after decades of warnings about the dangers of sex and HIV. If these warnings haven't worked by now, perhaps those spending public money on them should rethink their HIV strategy.

But what about the dangers of non-sexual infection with HIV? Neither those in the West coming over to South Africa nor those living in South Africa are likely to have had so many warnings. Tourists may well be aware of non-sexual risks, such as tattoo parlours, cosmetic outlets like barber shops and, perhaps most importantly, medical facilities. Go into a travel shop in many European countries and you will find medical equipment that you can bring with you on your trip, such as needles, syringes and sutures. Some of the well known guide books warn against some of the non-sexual dangers of HIV infection in addition to sexual behaviour.

Africans are not granted the benefits of access to affordable medical equipment or even of information about non-sexual HIV risk and how to protect themselves. It seems they are just not as important as tourists and others visiting the continent.

My guess is that people's heads, wherever they come from, have been so filled with information about condoms, casual sex, multiple partners and the rest, non-sexual risks will have little impact. And conflating gender based violence with HIV risk is not very helpful either. Gender based violence, whoever the victims, is wrong, it's not just wrong because victims may be infected with HIV. In fact, the majority of victims are not infected with HIV, but gender based violence is none the less abhorrent.

The truth is that the mainstream HIV industry has concentrated on sexual transmission of HIV to the exclusion of medical or cosmetic transmission. This was not so much the case in the early days, before the interference of massive levels of funding, commercial, political and religious interests. But now, the industry is all but silent on anything but sexual HIV transmission.

This is not because UNAIDS, the UN, WHO, CDC and other big players don't know about non-sexual HIV transmission. They have just chosen to ignore it. It's not quite clear why and I'd really like to hear their explanation. However, they simply spew out their guesswork figures, which already presuppose that heterosexual transmission accounts for most HIV transmission in African countries. They assume sexual transmission to be so high that there is not much scope for estimating anything more than a few percent for non-sexual transmission, unless the number of transmissions is higher than 100%, which wouldn't be beyond those clever UNAIDS epidemiologists. They can do anything with figures, it appears, except tell the truth.

Even campaigns about sexual transmission of HIV have been unconvincing, to date. But they are better than the complete silence that non-sexual transmission receives. People just don't realize the number of risks they face in their day to day lives. And people in African countries face more of those risks than those in Western countries. For a start, HIV prevalence is already very high in many Sub-Saharan countries. But medical facilities are often understaffed, underfunded, underequipped and oversubscribed. This is a disasterous combination if you consider how efficient medical transmission of HIV is, compared to sexual transmission.

Whatever happens during the World Cup, there will be little point in investigating what went wrong with the campaigns afterwards. The World Cup itself is irrelevant to the fact that millions of Africans face etremely high risk of contracting HIV every day and this has little or nothing to do with their sexual behaviour. The evidence for that is available now. It's time international health institutions stopped ignoring it.

Wednesday, June 2, 2010

For years, we have been blasted with ‘news’ about how successful Uganda was at controlling its HIV epidemic in the early days of the virus. Even articles about HIV in other countries were almost guaranteed to refer to Uganda’s ‘success’ and this was usually put down to the country’s adoption of ABC (Abstain, Be faithful and use a Condom) programmes. This is despite the fact that ABC campaigns didn’t exist anywhere in the late 1980s and early 1990s, at a time that HIV prevalence rates in Uganda were dropping fast. It wasn’t until many years later that Uganda and other countries were sold this rather spurious set of claims, which went so far as to claim that abstinence alone was responsible for falling HIV prevalence.

But it became rather embarrassing in the early 2000s, when Uganda’s prevalence rates appeared to be flatlining and perhaps even rising. Now that it has become too obvious for even the usual suspects at UNAIDS, CDC, WHO and the journalists who spread their wisdom to continue claiming that all is well in Uganda, people are asking what went wrong and how can the country get back on the right track. The UNAIDS Uganda country co-ordinator, Musa Bungudu, is interviewed and his answers show serious lack of understanding about HIV in general and HIV in Uganda in particular.

He emphasises the ‘behavioural change approach that helped Uganda to reduce HIV prevalence in the past’. Among the many who have echoed the praise for Uganda, there have been a few who have questioned the history of HIV there and especially the reasons given for Uganda’s early success and the country’s subsequent failures to eradicate the virus. In an article entitled ‘How Uganda Reversed Its HIV Epidemic’, a number of authors who worked in Uganda in the 1980s and 1990s (Gary Slutkin, Sam Okware, Warren Naamara, Don Sutherland, Donna Flanagan, Michel Carael, Erik Blas, Paul Delay and Daniel Tarantola) remember things very differently.

The story they give is that a campaign was mounted to inform people about all the modes of transmission and ways to avoid infection. Rather than just being a behaviour change campaign aimed at sexual behaviour, people were informed about medical transmission and other non-sexual modes, research and monitoring were carried out to determine who was at risk and why, etc. And these were, we are told, the usual strategies for an early Aids programme. The epidemic in Uganda was one of the first to peak. Therefore, the country would have benefited a lot more from such a campaign than countries where HIV was peaking later, once the ABC and abstinence only adherents managed to wrest most of the money from genuine health professionals.

In contrast, in Kenya, the epidemic peaked 10 years later, by which time politicians, religious leaders and commercial interests had taken the front seat and all reason and sense was stuck in the boot, where it languishes to this day. Interestingly, a completely coincidental sexually transmitted infection (STI) programme had been rolled out in Nairobi, just before HIV had been identified. During the time this programme was going on, HIV prevalence rose from very low rates (determined through stored blood samples) to prevalence rates of over 80%, only to drop dramatically as the STI programme was phased out. Aside from this remarkable coincidence, Kenya as a whole did as little as possible to reduce the spread of HIV and as much as possible to deny that there was even a serious epidemic in the country.

So, Uganda were successful in the early days of the epidemic and people often ask why, what did they do that other countries could have done and what were they doing that they are not doing now. Well, perhaps it was the adoption of the behavioural paradigm, so beloved by politicians, religious leaders and other bigots, the belief that HIV is mostly transmitted by unsafe heterosexual intercourse in African countries because, as the story goes, Africans have inordinately more sex than everyone else. And even Mr Bungudu, a Ugandan, doesn’t seem to feel the need to question the possibility that this behavioural paradigm is wrong.

He mentions that HIV prevalence was perhaps as high as 20% in the 1980s and that it dropped to about 6% by 2000, which would have been, to a large extent, due to very high death rates in the 1990s. He mentions that prevalence is even increasing but, most importantly, he notes that the rate of new infections is increasing. About half the HIV positive people who need antiretroviral treatment (ART), which means that HIV prevalence, the number of people living with HIV, should be rising. But Uganda continued with the programmes said to reduce HIV transmission, so why are they not working now?

One explanation appears to be that the country did, indeed, start off well, approaching every mode of transmission, not just sexual transmission. But once they embraced ABC, abstinence only and anything else that followed from the behavioural paradigm, transmission by all non-sexual routes started to increase. The country, effectively, abandoned a major part of their earlier campaign. In this pursuit, they were amply supported by their major donors, who didn’t want to hear about anything but sexual transmission and ineffective behaviour change campaigns. In fact, most countries are afraid to run any campaign that doesn’t explicitly mention sexual transmission to the exclusion of all other routes of transmission for fear of losing their funding. They are right to worry about losing their funding. But, as a result, they have lost control of the epidemic.

Bungudu then performs the classic UNAIDS trick of attributing most new HIV infections to low risk sex (entailing the contradiction that a virus that is difficult to transmit sexually is frequently transmitted sexually). Most new infections have been found to be among married people. Worse still, most of those infected are women whose husbands are HIV negative. Does Bungudu want to subscribe to the racist view that, not only do most Africans have a lot of sex, but also that many married women are sleeping with people other than their husbands, perhaps for money? To explain such high rates of sexual HIV transmission among married women whose husbands are HIV positive would require that they sleep with an awful lot of other men. HIV negative people married to HIV positive partners can remain HIV negative for years, even if they have regular unprotected sex.

But yes, Bungudu mentions high levels of unfaithfulness and all the other explanations that UNAIDS cling to, even saying that “a poor woman is likely to go out with a rich man for his money. If he is infected, she may get HIV.” What he doesn’t seem to appreciate is that this would take an awful lot of poor women having an awful lot of sex with a lot of rich people (are there many rich people in Uganda?). But we know that, for a long time, HIV prevalence was higher in richer sectors of the population. And this trend was as true for rich women as for rich men. The problem with everything that Bungudu says is that it all presupposes the truth of the behavioural paradigm. And it all ignores the obvious conclusion, that sexual behaviour does not explain why HIV is so high in some African countries and so low in most other countries.

Continuing the official line, which I suppose he has to do if wants funding to continue, Bungudu reflects on the fact that prevention messages are not getting to remote communities. He completely misses the fact that HIV prevalence in remote areas has always been lower than in urban areas. But once ‘messages’ start reaching these areas, in the form of assumptions about people’s sexual behaviour, HIV transmission tends to rise. This is being experienced in Gulu, now that the area is being ‘developed’. Prevalence has doubled in the last few years despite the fact that roads, hospitals, schools and other social services are being built.

It is a good thing that all these amenities are being built and I’m certainly not arguing otherwise. But if the HIV message continues to be about sexual transmission and excludes non-sexual routes, many more people in Gulu and other areas will continue to be infected. People like Bungudu and others need to open their eyes, to question what is happening and not just to repeat the prejudiced rubbish they have been fed by international health institutions.

The only hopeful thing Bungudu mentions is that Uganda’s HIV efforts are about 90% foreign funded. If the Ugandan government can find a way to provide more of the funding, they may be able to find a way to turn the epidemic around. But only if they also reject the simplistic and highly prejudicial maunderings that make up international HIV policy to date. Otherwise, the fact that most Ugandans are not able to access health services could be the only thing that gives them some protection from HIV. But if Ugandans are not prepared to stand up for other Ugandans in the face of such prejudice, no one else will.